Post-traumatic stress disorder

Summary

• Post-traumatic stress disorder (PTSD) arises as an immediate, delayed and/or protracted response to a traumatic or stressful event of a life threatening or catastrophic nature.
• The person developing the disorder does not have to be the one who was threatened directly. The disorder can also develop in witnesses to a traumatic event.
• Examples of life-threatening traumatic events that can cause post-traumatic stress include natural disasters, serious accidents (e.g., motor car accidents) and acts of violence (e.g. physical and sexual violence).
• About 8% of men and 20% of women exposed to at least one traumatic event will develop PTSD in their lifetime.
• The disorder tends to be more severe when the event involves deliberate human malice, as opposed to a "twist of fate".
• Symptoms such as flashbacks, difficulty sleeping, irritability, and nightmares must last for at least a month after a traumatic event for a diagnosis of PTSD to be made.
• If symptoms do not resolve within one to two months after the traumatic event, trauma focused cognitive behaviour therapy or medication treatment needs to be considered

Introduction 

PTSD arises as an immediate, delayed and/or protracted response to a traumatic event of a life threatening or catastrophic nature. These include natural disasters, acts of terrorism such as bomb blasts, hijackings,  physical assault and sexual events such as rape. The trauma involves direct personal experience of an event involving actual or threatened death or serious injury, or a threat to one's physical integrity, or witnessing an event that involves death or injury, or a threat to the physical integrity of another person.

Traumatic events that trigger PTSD must be life threatening and result in  feelings of intense fear, helplessness, or horror at the time of the event. Events such as grieving the loss of a loved one or marital conflict are not considered events that can lead to PTSD. One of the main differences between PTSD and other psychiatric disorders is that it is defined by a specific event and, as such, has a defined point of onset. Symptoms characterising PTSD include:

• Persistent re-experiencing of the event through intrusive thoughts, dreams, acting or feeling as if the event were reoccurring, and/or intense distress and emotion when exposed to cues that symbolise or resemble the event.
• Avoidance of stimuli associated with the event and attempts to numb their general responsiveness by avoiding thoughts, feelings, conversation, activities, places or people associated with the trauma.
• An inability to recall important aspects of the trauma and loss of interest in participating in activities.
• Feeling detached from others, having a restricted range of emotions and an inability to have loving relationships.
• Feeling little hope for the future.
• Increased arousal such as difficulty sleeping, irritability or angry outbursts, difficulty concentrating, increased vigilance and exaggerated or startled responses.

The above-mentioned symptoms must continue for at least a month and cause significant distress or impairment in social, occupational or other important areas of functioning. When PTSD lasts for longer than three months, it is considered to be chronic. Children can also develop PTSD and may have the above symptoms or other symptoms (e.g., acting out the trauma through play, drawings, or stories), depending on how old they are. As children get older, their symptoms are more like those in adults. Research suggests that children are more susceptible to developing PTSD than adults when exposed to similar traumatic events .

In general, individuals with PTSD respond to situations more intensely than those who do not have the disorder and experience significant distress and interference with their day-to-day functioning. Employment and relationship problems are also common.

Feelings of distress may also lead to development of depression, as well as other anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and generalised anxiety disorder.

Prevalence

Both trauma and PTSD are common and approximately 8 out of 100 individuals will develop PTSD at some time in their lives. Women are more than twice as likely as men to have PTSD. In South Africa, PTSD is common, owing to high rates of violent crimes, including physical and sexual assault,  hijacking and domestic violence. In studies in youth and in patients attending clinics, rates of PTSD of around 20% have been documented. .

Causes

The exact cause of PTSD remains unknown. However, it is agreed that a defining factor is that a person with PTSD must have experienced a profoundly distressing event, such as a natural disaster, assault, terrorism or serious accident.

The disorder tends to be more severe when the event involves deliberate human malice as opposed to a "twist of fate" or bad luck. But, because not all people who experience a serious stressor develop PTSD, other variables such as preceding trauma, previous mental health problems and the perceived lack of social support after the trauma may play a role in development of the disorder. Also individuals are more likely to develop PTSD if they were seriously hurt during the event, experienced a trauma that was very severe or long-lasting, felt that they were in danger or believed that a family member was in danger, had severe reactions during the event, such as feeling out of touch with reality or separate from their surroundings.

Symptoms

The symptoms of PTSD fall into three categories:

• Re-experiencing (i.e. intrusive symptoms)
• Avoidance and numbing
• Hyperarousal

Re-experiencing symptoms

Memories of the trauma can recur unexpectedly, and episodes called  "flashbacks" (feeling like you’re going through the event again or seeing it unfold before their eyes) can be intrusive. This happens as sudden, vivid memories, accompanied by painful emotions that can hold the person’s attention completely. An individual may also have nightmares of the traumatic event.

Avoidance symptoms

Avoidance symptoms often affect relationships with others: the person with PTSD often avoids close emotional ties with family, colleagues and friends. At first, the person feels emotionally numb and can complete only routine, mechanical activities. Later, when re-experiencing the event, the individual may alternate between a flood of emotions, caused by re-experiencing the trauma and an inability to feel or express emotions at all.

The person with PTSD avoids situations or activities that are reminders of the original traumatic event because such exposure can cause symptoms to worsen. Depression is not an uncommon sequela of the inability to resolve painful feelings. Some individuals also feel guilty because they survived a disaster.

Hyperarousal symptoms

Individuals with PTSD tend to be jittery, hyperalert and on the lookout for danger. They can become suddenly irritable or explosive, even when they are not provoked. They may have trouble concentrating or remembering current information, and, because of  terrifying nightmares, may develop insomnia.

A constant feeling that danger is near is often accompanied by exaggerated startle reactions. Many people with PTSD also attempt to rid themselves of their painful recollections of the event and experiences of loneliness and panic attacks by abusing alcohol or other drugs as "self-medication". Individuals with PTSD may show poor control over their impulses and may be at risk of self-harm.

When to see a doctor

Should the above mentioned symptoms persist beyond four to six weeks, it is important that you consult your doctor.

Diagnosis

The essential feature of PTSD is the development of characteristic symptoms following exposure to an extremely traumatic event.

The following criteria are indicated in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) as the diagnostic criteria for PTSD:

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

(2) The person’s response involved intense fear, helplessness or horror. In children, this may be expressed instead by disorganised or agitated behaviour.

B. The traumatic event is persistently re-experienced in one or more of the following ways:

(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. In young children, repetitive play may occur, in which themes or aspects of the trauma are expressed.

(2) Recurrent distressing dreams of the event. In children, there may be frightening dreams without recognisable content.

(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations and dissociative flashback episodes, including those that occur on awakening or when intoxicated). In young children, trauma-specific re-enactment may occur.

(4) Intense psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

(5) Physiological reactivity on exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event.

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:

(1) Efforts to avoid thoughts, feelings or conversations associated with the trauma.

(2) Efforts to avoid activities, places or people that arouse recollections of the trauma.

(3) Inability to recall an important aspect of the trauma.

(4) Markedly diminished interest or participation in significant activities.

(5) Feeling of detachment or estrangement from others.

(6) Inability to feel certain emotions (e.g. unable to have loving feelings).

(7) Sense of a foreshortened future (e.g. does not expect to have a career, marriage, children or a normal life span).

D. Persistent symptoms of increased arousal (not present before the trauma), as indicate by two or more of the following:

(1) Difficulty falling or staying asleep

(2) Irritability or outbursts of anger

(3) Difficulty concentrating

(4) Hypervigilance

(5) Exaggerated startle responses.

E. Duration of the disturbance (symptoms in Criteria B, C, D) of more than one month

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Acute PTSD: If duration of symptoms is less than three months.

Chronic PTSD: If duration of symptoms is three months or more.

PTSD with delayed onset: If onset of symptoms is at least six months after the trauma.

Treatment

Not everyone who experiences trauma requires treatment. Some recover with the help of family, friends or clergy. It is important to note that having an ongoing response for a few days or even 2-3 weeks to a traumatic event is normal. Recovery is an ongoing, daily process that happens in small steps.

However, there are many who will need professional help. Deciding if someone has PTSD can involve several steps. The diagnosis of PTSD is most often made by a mental health provider.

If you have suffered a trauma and recognise that you have symptoms of PTSD, then the following practical guidelines may be helpful:

• It is useful if you have experienced a traumatic event to learn more about common reactions to trauma and about PTSD.
• It is important not to isolate yourself from others, but to make an effort to talk to people that you trust who can offer concrete help and support.
• Find activities that help you relax e.g. listening to music, going for walks.  
• Make sure to keep taking part in activities that you enjoy or used to enjoy.
• Find a doctor or therapist who has experience in treating PTSD. Be truthful about your experience and symptoms. If you feel that the doctor or therapist is not right for you, you have the right to one that is. You also have the right to a second opinion.
• Have a doctor examine you for any additional medical problems.
• Avoid unhealthy behaviours.
• Find a support group for people with PTSD

There are effective treatments available for PTSD. The two main types are psychotherapy (a type of counselling) and medication. It is often necessary to combine psychotherapy and medication.

Therapy

Psychiatrists and other mental health professionals use a variety of effective therapeutic techniques to help people with PTSD work through their trauma and pain. Cognitive Behavioural Therapy (CBT) is one of the most effective treatments for PTSD. CBT usually involves meeting with your therapist once a week for 3-6 months. CBT focuses on correcting painful and intrusive patterns of thoughts and behaviours by examining (and challenging) faulty  thought processes and teaching relaxation techniques to assist with relaxation and managing distress. By examining and challenging thoughts about the trauma and changing these thoughts you can change the way you feel.

In addition to regular meetings with your therapist, you will get practice exercises or tasks to help you to use your new skills outside of therapy. Family therapy may also be recommended to assist the family of an individual who is experiencing PTSD.

Discussion or support groups can assist survivors of similar traumatic events to share their experiences and reactions to them. Group members help one another realise that many people would have done the same thing and felt the same emotions.

Medication

The most common class of medications prescribed for PTSD are antidepressants. Antidepressant medications, such as selective serotonin reuptake inhibitors (also known as SSRIs) may be particularly helpful in treating the core symptoms of PTSD - especially the intrusive symptoms, and are also associated with improvements in overall functioning.

Sertraline (Zoloft) and paroxetine (Aropax) are two SSRIs that are licensed for the treatment of PTSD in some countries. SSRIs are safe medications but are associated with side effects such as nausea, headache, feeling drowsy, tired and decreased interest in sex. Your doctor (GP or psychiatrist) should carefully monitor medication. Medication can take a few weeks to take effect and must not be stopped suddenly.

Because they are probably not helpful and because of the risk of addiction, benzodiazepines (also known as "tranquilisers"), should be avoided or used very judiciously.

Medication is often used in conjunction with therapy. The relief from symptoms that medication provides allows most patients to participate more effectively in psychotherapy when their condition may otherwise prohibit it.

There  is an increasing body of research indicating that  a single session of trauma debriefing is not effective in PTSD and in fact there is the potential for aggravating  symptoms and so routine debriefing of trauma survivors is not advocated.

Prevention

There is some preliminary evidence to suggest that intervening with medications or psychotherapy within a short time after a traumatic event may prevent the onset of PTSD, but further work in this area is still needed.

Reviewed by Professor Soraya Seedat, psychiatrist and co-director: MRC Unit on Anxiety Disorders, March 2011